Form I-566 Inter-Agency Record of Individual Requesting Change/Adju

Interagency Record of Request A, G, or NATO Dependent Employment Authorization or
Change/Adjustment To/From A, G, or NATO Status

USCIS
Form I-566

Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0027
Expires 12/31/2023

DRAFT
NOT FOR
PRODUCTION
03/09/2023
FOR USCIS OFFICE ONLY

Remarks:

A-Number:

Select this box if
Form G-28 is
attached.

To be completed by an
attorney or accredited
representative (if any).

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

Part 1. Information About You

Other Information

NOTE: The person requesting employment authorization or
change/adjustment of status provides the requested information.

5.

Date of Birth (mm/dd/yyyy)

6.

Country of Birth

7.

Country of Citizenship or Nationality

8.

Gender

9.

Marital Status

Full Legal Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

1.c. Middle Name

U.S. Mailing Address

Male

Single

(USPS ZIP Code Lookup)

Female

Married

Legally Separated

2.a. In Care Of Name (if any)

Divorced

Widowed

Marriage Annulled

Other
10.

2.b. Street Number
and Name
2.c.

Apt.

Alien Registration Number (A-Number) (if any)
► A-

Ste.

Flr.

11.

U.S. Social Security Number (SSN) (if any)
►

2.d. City or Town
2.e. State
3.

2.f.

12.

Department of State (DOS) Personal Identification
Number (PID)

13.

USCIS Online Account Number (if any)

ZIP Code

Is your current mailing address the same as your physical
address?
Yes
No

NOTE: If you answered “No” to Item Number 3., provide
your physical address in Item Numbers 4.a. - 4.e.

►
14.

Provide your relationship to the principal alien
(if applicable).

U.S. Physical Address
4.a. Street Number
and Name
4.b.

Apt.

Ste.

Flr.

15.a. Form I-94 Arrival-Departure Record Number (if any)

4.c. City or Town
4.d. State

Information About Your Last Arrival into the
United States
►

4.e. ZIP Code

Form I-566 Edition 12/02/21

Page 1 of 7

Part 1. Information About You (continued)

6.

Marital Status
Single

15.b. Passport or Travel Document Number

Married

Legally Separated

Marriage Annulled

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15.d. Expiration Date for Your Passport or Travel Document
(mm/dd/yyyy)

17.

Widowed

Other

15.c. Country That Issued Your Passport or Travel Document

16.

Divorced

Date of Your Last Arrival into the United States, On or
About (mm/dd/yyyy)
Your Current Immigration Status (for example, A-3
attendant, G-1 principal representative, NATO-2 other
representative)

7.

DOS Personal Identification Number (PID)

8.

USCIS Online Account Number (if any)
►

Information About the Principal Alien's Last
Arrival into the United States

9.a. Form I-94 Arrival-Departure Record Number (if any)
►

9.b. Passport or Travel Document Number

Part 2. Information About Principal Alien

NOTE: If you are the principal alien and submitting Form
I-566 on your own behalf, do not complete this section.

Principal Alien's Full Legal Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

9.c. Country That Issued His or Her Passport or Travel
Document

9.d. Expiration Date for His or Her Passport or Travel
Document (mm/dd/yyyy)

Part 3. Type of Request

1.c. Middle Name

1.

I am requesting (select only one box):

Principal Alien's U.S. Physical Address

Employment Authorization
(Proceed to Item Numbers 2.a. - 2.d.)

2.a. Street Number
and Name

Change/Adjustment of Status
(Proceed to Item Numbers 3.a. - 3.b.)

2.b.

Apt.

Ste.

Flr.

Requests for Employment Authorization
2.c. City or Town
2.d. State

2.e. ZIP Code

2.a. I am a/an (select only one box):
Son or Daughter
Spouse
Other Dependent Recognized by DOS

Principal Alien's Other Information
3.

Date Tour of Duty in the United States Expected to End
(mm/dd/yyyy)

4.

5.

Job Title

Country of Citizenship or Nationality

2.b. If you selected “Son or Daughter,” indicate your status if
you are 21 years of age or older (select only one box).
Full-time, Post-secondary Student
Disabled Person
2.c. If you selected a status in Item Number 2.b., provide
your age.
2.d. If you selected “Other Dependent Recognized by DOS,”
provide your category below.

Form I-566 Edition 12/02/21

Page 2 of 7

Part 3. Type of Request (continued)
Requests for Change/Adjustment of Status

Requestor's Certification and Signature
I certify, under penalty of perjury, that I provided or authorized
all of the responses and information contained in and submitted
with my request, I read and understand or, if interpreted to me
in a language in which I am fluent by the interpreter listed in
Part 5., understood, all of the responses and information
contained in, and submitted with, my request, and that all of the
responses and the information are complete, true, and correct.
Furthermore, I authorize the release of any information from
any and all of my records that USCIS may need to determine
my eligibility for an immigration request and to other entities
and persons where necessary for the administration and
enforcement of U.S. immigration law.

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PRODUCTION
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3.a. I am requesting a/an (select only one box):

Change of Nonimmigrant Status TO A, G, or NATO
Change of Nonimmigrant Status FROM A, G, or
NATO
Adjustment of Status Under Immigration and
Nationality Act (INA) Section 247(a) from
Immigrant to A or G Nonimmigrant
Adjustment of Status from A, G, or NATO
Nonimmigrant to Immigrant

Adjustment of Status Under 8 U.S.C. 1255b (Section
13 of the Act of September 11, 1957) from A-1, A-2,
G-1, or G-2 Nonimmigrant to Lawful Permanent
Resident
3.b. If you selected “Change of Nonimmigrant Status” TO or
FROM “A, G, or NATO,” provide the specific category
below.

NOTE: Form I-566 is not required if you have changed from
A, G, or NATO nonimmigrant status to asylum (protected)
status.

4.a. Requestor's Signature

4.b. Date of Signature (mm/dd/yyyy)

Part 5. Interpreter's Contact Information,
Certification, and Signature
Interpreter's Full Name

1.a. Interpreter's Family Name (Last Name)

1.b. Interpreter's Given Name (First Name)

Part 4. Requestor's Contact Information,
Certification, and Signature

2.

Interpreter's Business or Organization Name

Requestor's Contact Information
Provide your daytime telephone number, mobile telephone
number (if any), and email address (if any).
1.

Requestor's Daytime Telephone Number

2.

Requestor's Mobile Telephone Number (if any)

3.

Requestor's Email Address (if any)

Form I-566 Edition 12/02/21

Interpreter's Contact Information
3.

Interpreter's Daytime Telephone Number

4.

Interpreter's Mobile Telephone Number (if any)

5.

Interpreter's Email Address (if any)

Page 3 of 7

Part 5. Interpreter's Contact Information,
Certification, and Signature (continued)

Preparer's Certification and Signature

DRAFT
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PRODUCTION
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Interpreter's Certification and Signature

I certify, under penalty or perjury, that I am fluent in English
and

I certify, under penalty of perjury, that I prepared this request
for the requestor at their request and with express consent and
that all of the responses and information contained in and
submitted with the request are complete, true, and correct and
reflects only information provided by the requestor. The
requestor reviewed the responses and information and informed
me that they understand the responses and information in or
submitted with the request.

,

and I have interpreted every question on the request and
Instructions and interpreted the requestor's answers to the
questions in that language, and the requestor informed me that
they understood every instruction, question, and answer on the
request.
6.a. Interpreter's Signature

6.a. Preparer's Signature

6.b. Date of Signature (mm/dd/yyyy)

6.b. Date of Signature (mm/dd/yyyy)

Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this Request,
if Other Than the Requestor
Preparer's Full Name

1.a. Preparer's Family Name (Last Name)

1.b. Preparer's Given Name (First Name)

2.

Preparer's Business or Organization Name (if any)

Preparer's Contact Information
3.

Preparer's Daytime Telephone Number

4.

Preparer's Mobile Telephone Number (if any)

5.

Preparer's Email Address (if any)

Form I-566 Edition 12/02/21

Page 4 of 7

5.a. Page Number

Part 7. Additional Information
If you need extra space to provide any additional information
within this request, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this request or attach a separate sheet
of paper. Type or print your name and A-Number (if any) at the
top of each sheet; indicate the Page Number, Part Number,
and Item Number to which your answer refers; and sign and
date each sheet.

5.b. Part Number

5.c. Item Number

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PRODUCTION
03/09/2023
5.d.

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

1.c. Middle Name
2.

A-Number (if any) ► A-

3.a. Page Number

3.b. Part Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

3.c. Item Number

6.d.

3.d.

7.a. Page Number

4.a. Page Number

4.b. Part Number

4.c. Item Number

7.d.

4.d.

NOTE TO ALL REQUESTORS: Do not complete
Parts 8., 9., or 10. The agencies adjudicating
your request will complete these sections.
Form I-566 Edition 12/02/21

Page 5 of 7

FOR OFFICIAL USE ONLY
Part 8. Certification by Diplomatic Mission,
International Organization, NATO/HQ SACT,
or NATO Member State

8.a. Certifying Official's Signature

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NOT FOR
PRODUCTION
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NOTE: Certifying officer or official must have this
information and page to complete process.
1.

Certifying Official's Signature

I certify that the information provided in Parts 1., 2.,
and 3. of this Form I-566 is true and correct to the best
of my knowledge and according to our official records.

2.a. I further certify that the requestor's eligibility for
employment authorization was verified under the
provisions of a (select only one box):
Bilateral Agreement
Bilateral De facto Arrangement

8.b. Date of Signature (mm/dd/yyyy)

Address of Diplomatic Mission, International
Organization, NATO/HQ SACT, or NATO Member
State

9.a. Name of Diplomatic Mission, International Organization,
NATO/HQ SACT, or NATO Member State

9.b. Street Number
and Name
9.c.

Apt.

Ste.

Flr.

G-4 Regulations

9.d. City or Town

Additional Information About Agreement or Arrangement
2.b. Name of the Country With Which the Agreement or
Arrangement was Made

2.c. Select all applicable boxes.
Without a Numerical Limit

9.e. State

9.f.

ZIP Code

9.g. Province

9.h. Postal Code
9.i.

Country

With a Numerical Limit and This Requestor is
Within the Limit
For Change/Adjustment of Status
3.a.

I further certify that the principal alien is being
offered the following position:

Official Seal

3.b. DOS Notification Date (mm/dd/yyyy)

Certifying Official's Information
4.a. Certifying Official's Last Name

4.b. Certifying Official's First Name

5.

Certifying Official's Title

6.

Certifying Official's Daytime Telephone Number

7.

Certifying Official's Email Address (if any)

Form I-566 Edition 12/02/21

Page 6 of 7

FOR OFFICIAL USE ONLY

FOR OFFICIAL USE ONLY

Part 9. DOS, NATO/HQ SACT, and/or DOS
USUN Information

Part 10. USCIS Information

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NOT FOR
PRODUCTION
03/09/2023

1.a. Recommendation from DOS, NATO/HQ SACT, and/or
DOS USUN
Grant Request

Information About USCIS Immigration Services
Officer (ISO)

1.

ISO's Identification Number

For Change/Adjustment of Status only:

2.

USCIS Office

1.b. If you selected “Deny Request,” provide the reasons for
the recommendation.

3.

Office Telephone Number (including area code)

Deny Request

Information About USCIS Action Taken on This
Request

4.

2.

Date of Recommendation (mm/dd/yyyy)

Where was USCIS decision sent?
DOS OFM
DOS Protocol
NATO/HQ SACT

3.

Office Providing Recommendation
DOS OFM
DOS Protocol

DOS Visa

DOS USUN Host Country

DOS Visa

DOS USUN Host Country

NOTE: If the requestor filed under 8 U.S.C. 1255b
(“Section 13”), advise USCIS of findings.

5.a. Decision for Change/Adjustment of Status
Granted

Denied

Signature and Contact Information for
Recommending Official

5.b. Date of Decision (mm/dd/yyyy)

4.a. Recommending Official's Signature

5.c. If you selected “Granted,” provide the new status below.

4.b. Recommending Official's Daytime Telephone Number

6.a. Decision for Employment Authorization Request
Granted

Denied

6.b. Date of Decision (mm/dd/yyyy)
6.c. Employment Authorization Valid Until (mm/dd/yyyy)

6.d. Classification

7.a. Were DOS, NATO/HQ SACT, and/or DOS USUN Host
Country notified?
Yes
No
7.b. Date of Notification (mm/dd/yyyy)

Form I-566 Edition 12/02/21

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